Promoting Health and Wellbeing of Children and Families Through Relationship Based Interventions

Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. I aim to show how contemporary developmental science points us on a path to effective prevention, intervention, and treatment, with the aim of promoting healthy development and wellbeing of all children and families.

Friday, February 28, 2014

A popular blog post Why I Tried to Kill Myself at Penn is making its way around the college-age crowd. The author calls attention a high-stress a culture that does not value listening.

During my sophomore year at Penn, I tried to kill myself by swallowing a bottle of Wellbutrin. I spent 4 days in the hospital.Penn’s response? – Sending some administrator to see me in the hospital (HUP). The first and only thing that she said was, “Are we going to make this an annual pattern?” because I had been hospitalized the year before. I said “No” and she gave me her business card.After suicides, everyone laments, “Why didn’t they talk?” Often, we did. People just didn’t want to listen, because in the moment it was easier for everyone if you put on a smile and pretended to be okay.

A parent recently described calling the emergency student support services when she was worried about her son's emotional state during his first semester at college. After a five minute conversation, she was told by the person who responded to her call, " We can make an appointment with the psychiatrist to see if he needs medication."I thought about these two stories when a study, a survey of 1,829 people being prescribed antidepressants, was released showing a much higher than expected rate of serious psychological side effects:

Over half of people aged 18 to 25 in the study reported suicidal feelings and in the total sample there were large percentages of people suffering from 'sexual difficulties' (62%) and 'feeling emotionally numb' (60%). Percentages for other effects included: 'feeling not like myself' (52%), 'reduction in positive feelings' (42%), 'caring less about others' (39%) and 'withdrawal effects' (55%). However, 82% reported that the drugs had helped alleviate their depression.

Professor Read concluded: "While the biological side-effects of antidepressants, such as weight gain and nausea, are well documented, psychological and interpersonal issues have been largely ignored or denied. They appear to be alarmingly common."

Psychiatric medication side effects are a double-edged sword. The first, that receives the most, though as indicated by this study insufficient, attention is from the medication itself. But the second, and equally if not more serious, is the way prescribing of psychiatric medication becomes a replacement for listening. What makes us human is our ability to empathize. Drawing from both Buddhism and psychoanalysis, the "presence of mind" of another person is responsible for therapeutic healing. "Being with," "bearing witness," are other phrases that describe this phenomenon. When we jump to a pill we run the risk of skipping this step. If the medication itself also has psychological side effects, it is not surprising that, in combination with feeling alone and unrecognized, a person might attempt suicide.Psychiatric medication may be necessary when an individual is unable to function without it. Ideally such a determination is made in the setting of both psychotherapy and other self-regulating activities such as yoga or meditation. But that is not the way these medications are used. Because they can be so effective at eliminating distress in the short term, our fast-paced, quick-fix culture makes them very appealing, almost irresistible.I decided to include the topic of legalization of marijuana in this post as a kind of cautionary tale. In California cannabis is commonly prescribed to treat anxiety. Psychiatric diagnoses and drug prescribing are often based on symptoms alone, as is well captured in this amusing though disturbing anecdote from a Psychology Today post by psychologist Jonathan Shendler:

During my first week as a psychiatry department
faculty member, a fourth-year psychiatry resident—I will call her Gabrielle—staffed
a case with me. She gave me some demographic information about her patient (38,
White, female) and then proceeded to list the medications she was prescribing.
The rest of our conversation went something like this:“What are we treating her for?” "Anxiety." "How do we understand her anxiety?"Gabrielle cocked her head
to the side with a blank, non-comprehending look, as though I had spoken a
foreign language. I rephrased the question.“What do you think is
making your patient anxious?”She cocked her head to the
other side. I rephrased again.“What is causing her
anxiety?"

Gabrielle thought for a
moment and then brightened. “She has Generalized Anxiety Disorder.”“Generalized anxiety
disorder is not the cause of her anxiety,” I said. “That is the term we use to
describe her anxiety. I am asking you to think about what is making your
patient anxious.”She cocked her head again.“What is going on
psychologically?”“Psychologically?”

As we are on the cusp of general legalization of marijuana (that I do not oppose) it becomes imperative that psychiatric medications not replace listening. It is essential that we protect time and space for being present, for curiosity, for empathy. Otherwise we are simply offering another way, and one that is not without side effects itself, to devalue the role of human relationships in healing.

Sunday, February 16, 2014

A
recent article in the New Republic, provocatively titled “ADHD Does Not Exist,”
starts out well enough. The author, a psychiatrist with “over 50 years
experience” points to the fact that ADHD describes a collection of symptoms, rather
than their underlying cause. Using stimulants to control these symptoms, he
argues, is analogous to prescribing pain medication for cardiac chest pain rather than
addressing the underlying circulatory problem. But my antennae went up when he applied his views to a case, and concluded that his patient, a 12-year-old-boy, was misdiagnosed with ADHD,
when in fact he had bipolar disorder. My level of alarm rose when he went on to describe his treatment:

In William’s case, the family agreed to try medication first
without psychotherapy, to see what kind of impact the pharmaceutical treatment
could have. The first medication we tried, an anti-seizure drug commonly
prescribed for bipolar disorder, reduced the boy’s mood and behavioral symptoms
dramatically but resulted in side effects including upset stomach and
dizziness. We started William on lithium, and within two months we found a
dosage that worked well for him, reducing his symptoms to very mild levels,
with no significant side effects.

There
is no mention of developmental history or family relationships. There is no
exploration of the context in which these symptoms occur, and certainly no
evidence that William’s experience being bounced from medication to medication
is being considered. Dr. Saul in essence replaces one treatment of symptoms without
determining the underlying cause with another treatment of symptoms without
addressing the underlying cause.

The
author points to a strong family history of bipolar disorder to support his
diagnosis. Statistics from theNational
Institute of Mental Health indicate that when a parent or sibling hasbipolardisorder, a child is up to six times more likely to develop the illness.

But when it comes to an individual child and family, not only
are statistics meaningless, but they may also preclude exploration of the
underlying cause of the child’s symptoms. These symptoms are usually due to a complex interplay of biology and environment. Statistics do not speak to the effect of early intervention in decreasing the risk. Consider Jacob, a five-year-old boy I
saw recently in my behavioral pediatrics practice. He was adopted, and two
biological relatives had bipolar disorder. A pediatrician, his adoptive parents
and a neurologist suspected that he too had the disorder. But with space and
time to hear the story, the following emerged.

Jacob had been an easy baby. Then when he was about two, he
experienced a number of significant losses. A foster child with whom he was
very close was removed from the home because of behavior problems. Just weeks
after his adoptive mother, Alice, learned she was pregnant, her sister died
suddenly of a cerebral hemorrhage. Jacob’s maternal grandmother, in the face of
the loss of her own daughter, threw herself in to caring for Jacob’s baby
sister. Jacob’s mother wept in my office as she spoke of her own loss, not only
of her sister, but also of her mother who withdrew in the face of her grief. Shortly
after these events, Jacob’s behavior problems began in earnest. He became
alternatively clingy and aggressive. When I saw the family, no one had slept
through the night for a long time.

Jacob might very well have a biological vulnerability to
emotional dysregulation inherited from his parents who carried the bipolar
label. But multiple losses, subsequent disruptions in attachment relationships,
sleep disruption, and other factors had significant roles to play in
development of his symptoms. Had he, like William, been prescribed medication
for his symptoms, this story, and the meaning of his behavior, would not have
been heard. For every child I see in my practice, there is a story, often equally complex, behind the symptoms.

Rather than offer time and space for the nuances, complexities
and uncertainties of human behavior and relationships, the DSM (Diagnostic and Statistical Manual of Mental Disorders) paradigm, with
its diagnoses of disorders based on symptoms, often followed by prescribing of
medication, creates an aura of certainty, as in “you have X and the treatment
is Y.” But there is virtually no evidence of any known biological processes
corresponding to either ADHD or bipolar disorder (or any other DSM diagnoses, for that matter.)This certainty implied in the giving of a
diagnosis and prescribing of medication has a kind of comfort, but also a real danger. There is no room for
curiosity, for wonder, for not knowing. Jacob’s behavior was a form of communication. Giving
medication to control his behavior is in effect a silencing of that communication.

A
recent New York Times article, “The Dangers of Certainty,” addresses this issue
in a very different context. The author describes how he was profoundly
influenced by the 1973 BBC documentary series, “The Ascent of
Man,” hosted by Dr. Jacob Bronowski. The article describes an episode in which Bronowski discusses Heisenberg’s uncertainty principle.

Dr.
Bronowski’s 11th essay took him to the ancient university city of Göttingen in
Germany, to explain the genesis of Werner Heisenberg’s uncertainty principle in
the hugely creative milieu that surrounded the physicist Max Born in the 1920s.
Dr. Bronowski insisted that the principle of uncertainty was a misnomer,
because it gives the impression that in science (and outside of it) we are
always uncertain. But this is wrong. Knowledge is precise, but that precision
is confined within a certain toleration of
uncertainty….Dr. Bronowski thought that the uncertainty principle should
therefore be called the principle of tolerance. Pursuing knowledge means
accepting uncertainty. ..In the everyday world, we do not just accept a lack of
ultimate exactitude with a melancholic shrug, but we constantly employ such
inexactitude in our relations with other people. Our relations with others also
require a principle of tolerance. We encounter other people across a gray area
of negotiation and approximation. Such is the business of listening and the
back and forth of conversation and social interaction.

As
he eloquently put it, “Human knowledge is personal and responsible, an unending
adventure at the edge of uncertainty.”The relationship between humans and
nature and humans and other humans can take place only within a certain play of
tolerance. Insisting on certainty, by contrast, leads ineluctably to arrogance
and dogma based on ignorance.

The
episode takes a dark turn when the scene shifts to Auschwitz, where many members
of Bonowski’s family were murdered. The article’s author, a professor of
philosophy at the New School, offers this interpretation:

The pursuit of scientific
knowledge is as personal an act as lifting a paintbrush or writing a poem, and
they are both profoundly human. If the human condition is defined by
limitedness, then this is a glorious fact because it is a moral limitedness
rooted in a faith in the power of the imagination, our sense of responsibility
and our acceptance of our fallibility. We always have to acknowledge that we
might be mistaken. When we forget that, then we forget ourselves and the worst
can happen.

I
can already hear the shouts of outrage that I dare to compare mental health
care with Nazism. Having grandparents who survived a concentration camp, I know well that this is a highly fraught subject. But of course that is not what I am doing. I am simply pointing
to this article as a beautiful articulation of the value of uncertainty, especially
in the context of understanding human behavior.

Thursday, February 6, 2014

Recently I reviewed my son's high school essay on To Kill A Mockingbird. I was surprised and pleased to rediscover, or perhaps discover for the first time now that I was viewing it from the perspective of over 50 years of life experience, the profound wisdom of the book.

In one of the novel's most famous quotes, Atticus tell his daughter Scout, "you never really understand a person until you consider things from his point of view, until you climb in his skin and walk around in it."

I now understand this as a description of the essence of being human, namely the capacity to be curious about the meaning of another person's behavior. Peter Fonagy, whose research has shown how the development of this capacity is intimately linked to healthy emotional development, argues, in a way analogous to Bowlby's description of attachment behavior, that this capacity has evolutionary significance, and is essential to survival. My book Keeping Your Child in Mind presents this research for a general audience, showing its application to parenting.

I wonder if our current epidemic of "ADHD" is related to having lost sight of this essential human quality. The most common phrases I hear from parents who come to my office with concerns of problems of inattention and impulsivity are, "he never listens," followed by "tell me what to do to make him listen."

Perhaps ADHD is a problem of not listening. But it is the adults who are not listening to each other. In our fast-paced, technology driven age, we rarely take the time to listen to each other, to put ourselves in another person's skin.

When Scout comes home from her first day of school upset with the teacher, her father tells her, "she's new too." He is helping Scout to understand her teacher's perhaps impatient behavior from a different point of view, to appreciate that the teacher herself may have been stressed and overwhelmed.

Recently parents of 4-year-old Sam, who was having problems of impulsivity in the classroom, spent a good portion of our visit expressing anger at his teacher, who they were convinced just didn't like their child. But with a full hour, and a quiet space to tell the story, they came to recognize that just as they could get overwhelmed at times by their son's behavior, so could the teacher be overwhelmed. Perhaps she felt defensive when the parents got angry, as she was trying her best in less than ideal classroom setting, with a low teacher: student ratio.

In turn, with the parents and teacher listening to each other and not behaving defensively, they could reach a new level of understanding of what set Sam off, and to develop strategies both at home and in school to help him to feel calm.

I wonder if the current epidemic of what we call "ADHD" represents a loss of this capacity to put ourselves in another person's skin. I have had the pleasure of an email exchange with the New York Times journalist Alan Schwartz, whose multiple superb article, most recently The Selling of ADHD, have served to bring the subject to the forefront of public discourse. I am hopeful that he will help us to see the big picture, rather than to place blame.

I have wondered in conversation with him if the whole phenomenon of "ADHD" is itself a symptom of larger social ills, particularly in the education and health care systems as well as the medical education system. People, including parents, teachers, pediatricians and mental health professionals, are feeling overwhelmed and not heard.

The large scale medication of a whole generation of children has potential serious and profound long-term effects. These include the silencing of children whose symptoms represent complex underlying problems, as well as abuse of stimulant medication by high school and college students.

We will never go back to the slow pace depicted in the 1960 novel, where there are large expanses of time to listen. But we need to be very careful not to give it up completely. For it does take space and time to put yourself in another person's skin. If that is the essence of what makes us human, we need to value that space and time.

the baby connects

About Me

I am a pediatrician and writer with a long-standing interest in addressing children’s mental health needs in a preventive model. I have practiced general and behavioral pediatrics for over 20 years, and currently specialize in early childhood mental health. I am the author of The Developmental Science of Early Childhood:Clinical Applications of Infant Mental Health Concepts from Infancy Through Adolescence" ( 2017)"The Silenced Child:From Labels, Medications, and Quick Fix Solutions to Listening, Growth, and Lifelong Resilience" ( 2016) "Keeping Your Child in Mind: Overcoming Tantrums, Defiance, and other Everyday Problems by Seeing the World Through Your Child's Eyes"(2011) " I am on the faculty of UMass Boston Infant-Parent Mental Health Program, William James College, the Brazelton Institute, and the Austen Riggs Center.